When you ask for an appeal, your Plan has thirty (30) days to give you an answer. You can ask questions and give any updates (including new medical documents from your providers) that you think will help the Plan approve your request. You may do that in person, in writing or by phone. You may also ask to review your appeal file during the appeals process or ask for a copy of your appeal at no charge.
You can ask for an appeal yourself. You may also ask a friend, a family member, your provider or a lawyer to help you.
When you appeal, you and any person you have chosen to help you can see the health records and criteria your Plan used to make the decision. If you choose to have someone help you, you must give them written permission.
Expedited (faster) Appeals
You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health or to your ability to regain your good health. This faster review is called an expedited appeal.
Provider Requests for Expedited Appeals
If your provider asks us for an expedited appeal, we will give a decision no later than seventy-two (72) hours after we get the request for an expedited appeal. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within three (3) days from your appeal.
Member Requests for Expedited Appeals
The Plan will review all member requests for expedited (faster) appeals. If a member’s request for an expedited appeal is denied, we will call right away. We will usually call within two (2) hours of the decision. We also will tell the member and the provider in writing if the member’s request for an expedited appeal is denied. We will tell you the reason for the decision. The Plan will mail you a written notice within two (2) calendar days.
When the member does not agree with the Plan’s decision to deny an expedited appeal request, he or she may call and file a grievance with the Plan.
When your Plan denies a member’s request for an expedited appeal, there is no need to make another appeal request. The appeal will be decided within thirty (30) days of your request. In all cases, we will review appeals as fast as a member’s medical condition requires.
Timelines for Standard Appeals
If we have all the information we need, you will have a decision in writing within thirty (30) days from your appeal. If we need more information to decide about your appeal, we will:
- Call you to let you know we need to take additional time
- Write to you and tell you what information is needed.
- Explain why the delay is in your best interest.
- Decide no later than fourteen (14) days from the day we asked for more information.
Decisions on Appeals
When we decide your appeal, we will send you a letter. This letter is called a Notice of Decision. If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within one hundred twenty (120) days from the day you get your Notice of Decision from your Plan.
State Fair Hearings
If you do not agree with your Plan’s decision on your appeal, you can ask for a State Fair Hearing. In North Carolina, State Fair Hearings include an offer of a no cost and voluntary mediation session. This meeting is held before your State Fair Hearing date.
No Cost and Voluntary Mediations
When you ask for a State Fair Hearing, you will get a phone call from The Mediation Network of North Carolina. The Mediation Network will call you within five (5) business days after you request a State Fair Hearing. The state offers this no cost meeting to help resolve your disagreement quickly. These meetings are held by phone.
You do not have to accept this meeting. You can ask to schedule just your State Fair Hearing. When you do accept, a Mediation Network counselor will lead your meeting. This person does not take sides. A member of your Plan’s review team will also attend. If the meeting does not help with your disagreement, you will have a State Fair Hearing.
State Fair Hearings
State Fair Hearings are held by the North Carolina Office of Administrative Hearings (OAH). An administrative law judge will give you a decision. You can give any updates and facts you need to at this hearing. A member of your Plan’s review team will attend. You may ask questions about the Plan’s decision. The judge in your State Fair Hearing is not a part of your health plan in any way.
If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court.
State Fair Hearings for Disenrollment Decisions
You can also ask for a State Fair Hearing for decisions that you disagree with about changing your health plan.
You, or your authorized representative, may ask for a State Fair Hearing if you disagree with a decision to:
- Deny your request to change plans
- Approve a request made by WellCare of North Carolina for you to leave the plan.
You can ask for a State Fair Hearing within thirty (30) days from the day you receive a notice informing you of the decision about your request to change plans or WellCare of North Carolina’s request for you to leave the health plan.
Important Phone Numbers
The NC Mediation Network can be reached at 1-336-461-3300, Monday through Friday, 8 a.m. to 5 p.m.
Continuation of Benefits During an Appeal
Sometimes a Plan’s decision reduces or stops a service you are already receiving. You can ask to continue this service without changes until your appeal is finished. You can also ask the person helping you with your appeal to make that request for you.
The rules in the section are the same for Appeals and State Fair Hearings.
There is a special rule about continuing your service during your appeal. Please read this section carefully!
- You always have thirty (30) days to ask your Plan to keep paying for your services until you get your appeal decision.
- Your Plan will always pay for your services to continue from the day that you ask.
- Your Plan will keep paying for your service every day until your appeal is decided.
You must do two (2) things for your Plan to keep paying for services during your appeal or State Fair Hearing:
- Ask your Plan for an appeal, or ask for your State Fair Hearing
- Ask for your service to stay the same while you appeal.
Remember to ask your Plan to continue your services as soon as possible. Three (3) things may happen to your service, depending on when you ask your Plan.
- When you do not ask for your Plan to keep paying for your service, the Plan will stop paying for it on the 10th day after the date on your Notice. You will also see the exact date your service will change on the first page of your Notice.
- When you ask your Plan to keep your services the same earlier than the 10th day after your Notice date, your Plan will pay for every day of your service until your appeal is finished.
- When you ask your Plan to keep your services the same after the 10th day after your Notice date, your Plan may stop paying for some days of your service.
The Plan will pay for your services from the day you ask for them to continue until you the day get your appeal decision.
Your appeal might not change the decision the health plan made about your services. When your appeal doesn’t change the health plan’s decision, the health plan may require you to pay for the services you received while waiting for a decision.
Sometimes a provider may ask for less hours or amounts of your service than was approved in your old request. When this happens, you will get the hours or amounts that your provider asked for in the new request until your appeal is decided. This will be less than the hours or amounts that were in the old approval.
If You Have Problems with Your Health Plan You Can File a Grievance
We hope our health plan serves you well.
For Medicaid members, a grievance and a complaint are the same thing. Contacting us with a grievance means that you are unhappy with your health plan, provider or your health services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will record your call, your problem and our solution. We will inform you that we have received your grievance in writing. We will also send you a written notice when we have finished working on your grievance.
You can ask a family member, a friend or a legal representative to help you with your complaint. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filing out any forms, we can help you.
Resolving your grievance
We will let you know in writing that we got your grievance within five (5) days of receiving it.
- We will review your complaint and tell you how we resolved it in writing within thirty (30) days from receiving your complaint.
If your grievance is about your request for an expedited (faster) appeal, we will let you know quickly and in writing that we got your grievance. We will reply in writing within twenty-four (24) hours after we get your grievance. We will review your complaint about the denial of an expedited appeal quickly. We will tell you how we resolved it in writing within five (5) days of getting your complaint.